Citation Nr: 0021745
Decision Date: 08/16/00 Archive Date: 08/23/00
DOCKET NO. 95-12 389 ) DATE
)
)
On appeal from the
Department of Veterans Affairs Regional Office in Washington,
DC
THE ISSUE
Entitlement to service connection for paranoid schizophrenia.
REPRESENTATION
Appellant represented by: Disabled American Veterans
WITNESS AT HEARING ON APPEAL
Appellant
ATTORNEY FOR THE BOARD
R. A. Caffery, Counsel
INTRODUCTION
The veteran served on active duty from September 1966 to
September 1968. He served in Vietnam for almost 12 months
but received on awards or decorations indicative of combat
service. His listed military occupation was lineman.
This is an appeal from a December 1994 rating action by the
Department of Veterans Affairs (VA) Regional Office (RO),
Washington, D.C., which denied entitlement to service
connection for paranoid schizophrenia. In December 1996 the
veteran testified at a hearing before a member of the Board
of Veterans' Appeals (Board) sitting in Washington, D.C.
Later in December 1996 the Board remanded the case to the
regional office for further action. The regional office
confirmed and continued the prior denial in 1997 and 1999.
The case is again before the Board for further appellate
consideration.
FINDINGS OF FACT
1. All relevant evidence necessary for an equitable
disposition of the veteran's appeal has been obtained by the
regional office.
2. A psychiatric disability was not demonstrated during the
veteran's period of active military service.
3. A psychiatric disability, diagnosed as schizophrenia, was
initially medically demonstrated many years following the
veteran's release from active duty and has not been shown to
be related to his period of active service.
CONCLUSION OF LAW
The veteran's paranoid schizophrenia was not incurred in or
aggravated during his active service and may not be presumed
to have been incurred in service. 38 U.S.C.A. §§ 1101, 1110,
1112, 1113, 5107 (West 1991); 38 C.F.R. §§ 3.307, 3.309
(1999).
REASONS AND BASES FOR FINDINGS AND CONCLUSION
The Board finds the veteran's claim to be "well grounded"
within the meaning of 38 U.S.C.A. § 5107(a); effective on and
after September 1, 1989. That is, the Board finds that he
has presented a claim which is plausible. The Board is also
satisfied that all relevant facts regarding the claim have
been properly developed.
I. Background
The veteran's service entrance examination included
complaints of headaches and dizziness or fainting spells, but
he was found to be qualified for entry. Service department
treatment records show no complaints, symptoms or treatment
for anything related to a nervous condition. On a medical
history form completed by the veteran at the time of his
separation from service in July 1968 he checked the blocks
indicating that he had or had had dizziness or fainting
spells and nervous trouble, but on the medical examination
the evaluation, including the psychiatric evaluation was
normal in all respects.
The veteran's initial claim for VA disability benefits was
submitted in October 1968. He claimed service connection for
a foot condition.
By rating action dated in October 1968 the regional office
granted entitlement to service connection for pes planus.
The veteran was afforded a VA examination in October 1969.
The psychiatric evaluation was reported to be normal.
In December 1974 the veteran submitted a claim for service
connection for a psychiatric condition. The claim was denied
in a January 1975 rating action. The veteran disagreed with
the decision and was sent a statement of the case in February
1975; however, he did not submit a substantive appeal. He
had been hospitalized by the VA from November 1974 to January
1975 for a left frontal intracerebral hemorrhage secondary to
trauma and exogenous depressive reaction. His mental
condition was evaluated as an organic psychosis secondary to
the hematoma. A history of extensive past drug use was noted
as was a two week history of progressive personality change
immediately prior to admission.
The veteran was afforded a VA psychiatric examination in
September 1979. The diagnosis appeared to be drug abuse with
possible organic psychosis manifested by hallucinosis.
A March 1980 statement by W. Statom, M.D., reflected that the
veteran had been treated in April 1978 and January 1979 for
excessive alcohol use.
Records from the District of Columbia, Department of Human
Resources, reflects the veteran's treatment from February
1975 to June 1978. A history of drug use was noted and a
diagnosis of paranoid schizophrenia was entered in January
1977. In June 1978 the diagnosis was alcohol addiction.
The veteran was afforded a VA psychiatric examination in
October 1980. The diagnosis was deferred until a
psychological report was completed to differentiate between
organic delusional syndrome and paranoid schizophrenia. It
was stated that the diagnosis of organic delusional syndrome
seemed the more likely diagnosis.
In March 1994 the veteran submitted a claim for service
connection for schizophrenia.
An April 1994 statement by Harold Kaufman, M.D., reflected
that the veteran had been a patient under his care since
August 1988 at the St. Elizabeth's Hospital. It was noted
that in 1974 the veteran had suffered a left front
intracerebral hemorrhage with prolonged unconsciousness. The
relationship of that condition to possible cognitive damage
was unclear. The veteran also claimed auditory and visual
hallucinations beginning in 1969 on an intermittent basis.
He was admitted to the St. Elizabeth's Hospital and D.C.
General Hospital in the late 1970's because of those
symptoms. He exhibited paranoid thinking. After being
acquitted from criminal charges by reason of insanity in 1985
he had been confined to a division of the St. Elizabeth's
Hospital where he had remained continuously since that time.
At the current time the veteran's symptoms of schizophrenia
were well controlled by medication that he was receiving
daily. His prognosis had been good, but he remained severely
compromised by his psychiatric condition which Dr. Kaufman
dated back to at least 1969.
In a January 1995 statement Eugene C. Stammeyer, Ph.D.,
reflected that he had conducted an extensive psychological
evaluation of the veteran between May and September 1994.
The veteran had requested that he provide an opinion as to
whether the veteran's mental disorder, schizophrenia, had
resulted from his service in the U.S. Army. Dr. Stammeyer
said he did not have access to the veteran's military records
but it was his professional opinion, based on his evaluation,
that there was no evidence of symptoms of a mental disorder
prior to the veteran's active service or even during service,
prior to his service in Vietnam in 1967. He stated that,
however, the veteran's mental condition clearly deteriorated
during his one-year service in Vietnam and his psychotic
symptoms continued after his discharge. He therefore
concluded that the veteran's mental disorder developed during
his military service in Vietnam.
A December 1994 statement by David L. Shapiro, Ph.D.,
reflects that in his opinion, based on personal examination
and a review of extensive psychiatric records, that the
veteran's mental disorder, paranoid schizophrenia, resulted
from his service in the U.S. military service. He stated
that there was no evidence from either clinical interview,
history or psychological testing that the condition existed
prior to service.
In a December 1994 statement, Dr. Kaufman indicated that the
veteran had been a patient under his care at the St.
Elizabeth's Hospital since August 1987. Shortly thereafter,
the veteran described hallucinatory experiences and
delusional ideation that had occurred for the first time
during his military service. Dr. Kaufman stated that the
reports appeared sincere and too detailed to be fabricated.
The veteran also reported that the mental problems were
worsened by the emotional trauma to which he was subjected in
Vietnam while on active duty. For those reasons, it was his
professional opinion that the veteran's mental disorder began
while he was in military service and was aggravated while he
was on active duty. The veteran had explained that his
failure to report the hallucinations and delusions at the
time resulted from his embarrassment at admitting them to
anyone. In addition, the fact that the symptoms were
intermittent caused the veteran to believe that they would
remit spontaneously.
The veteran was afforded a VA psychiatric examination in
January 1995. Various findings were recorded. The examiner
stated that the question of the onset of the symptoms of
hallucinations was not at all clear. The veteran stated that
he had visual hallucinations when he was frightened in
Vietnam and was using drugs. He stated that he had had
voices in his head criticizing him throughout the years since
that time. The examiner commented that the evidence that
those occurred was based mainly on the veteran's story. The
examiner noted that the veteran presented statements from a
psychiatrist and two psychologists indicating their belief
that the veteran had symptoms while he was in Vietnam and
soon thereafter but those were subjective and based on
opinion. The current psychiatric diagnosis would appear to
be schizophrenia in good remission. The time of onset of the
symptoms was not at all clear, and there was no evidence that
the veteran had those symptoms within several years of his
military service except for his current statements that the
symptoms occurred during that time. He stated that to arrive
at a definitive opinion the claims folder and perhaps the
records from St. Elizabeth's Hospital in 1985 had to be
examined. At the current time he was unable to say that the
symptoms occurred during or soon after the veteran's military
service.
The veteran was again afforded a VA psychiatric examination
in February 1997. The examiner commented that the veteran's
own statements were the only documentation of the time of
onset. The assessment as to onset of the condition was
complicated by amply documentation of the extensive use of
illicit drugs starting in Vietnam; making it difficult to
determine if his early schizophrenia-like symptoms were drug
effects or really the manifestations of the schizophrenic
process. It was further noted that schizophrenia typically
occurred between the late teens and the mid-thirties; however
that information could not be applied in the individual case
in the absence of supporting material. That physician was
unable to come to a conclusion about the onset of the
veteran's psychiatric disorder.
In a September 1997 statement John J. Kelley, M.D., noted
that the veteran had initially been admitted to the St.
Elizabeth's Hospital in November 1985 after being found not
guilty by reason of insanity. He currently had diagnoses of
chronic paranoid schizophrenia; alcohol abuse, in remission;
cannabis abuse, in remission and PCP abuse, in remission. He
was receiving medication. Dr. Kelley stated that the veteran
had reported hearing voices beginning in 1967 while in the
U.S. Army stationed in Vietnam. He stated that at that time
he did not seek psychiatric treatment because he was too
embarrassed to admit hearing the voices. The voices
persisted until he was treated with neuroleptic medications.
Dr. Kelley stated that since the veteran stated that the
auditory hallucinations initially manifested themselves prior
to his discharge in September 1968 it would seem that his
schizophrenia became clinically significant prior to his
military discharge.
The veteran was again afforded a VA psychiatric examination
in May 1999. The veteran claimed that he had heard voices
while in Vietnam after being there for about six months.
However, he did not seek any medical care. The veteran also
claimed that he obtained psychiatric medication during
service. The examiner reviewed the veteran's military
medical records and could not find any reference of a
psychiatric visit or psychiatric medications.
The veteran stated that after discharge he began attending a
university in about January 1969. At that time the voices
became hostile and he could not concentrate. He had several
jobs but could not keep them. It was during that time he
became involved with drugs. In the early 1970's he had gone
to the D.C. General Mental Health Clinic and had received
psychiatric medication. Throughout the veteran's period in
Vietnam he used marijuana and continued with other drugs
following his return to the United States. His initial
psychiatric treatment had been between 1970 and 1973 at D.C.
General Hospital. His initial inpatient treatment had been
at St. Elizabeth's Hospital in 1985. He had had prolonged
treatment at St. Elizabeth's Hospital for schizophrenia. The
examiner noted the veteran's claim that the condition had
begun while he was in service but also noted that there was
no documentation of that. Although he believed the veteran
might be accurate in reporting that, there was no way to
confirm it. There was also no documentation of psychiatric
treatment in the early period following his discharge from
service. The serious cerebral insult in 1975 with
intracerebral hemorrhage might have worsened his psychiatric
condition or consolidated it. It was well known that strokes
or other organic conditions could either bring on or
exacerbate schizophrenia that had previously been latent.
The veteran was clearly psychotic in 1985 and seemed to have
come under reasonably good control in the 10 years he was in
St. Elizabeth's Hospital.
II. Analysis
Service connection may be granted for disability resulting
from disease or injury incurred in or aggravated by wartime
service. 38 U.S.C.A. § 1110.
Where a veteran served ninety (90) days or more during a
period of war and a psychosis becomes manifest to a degree of
10 percent within one year from date of termination of such
service, such disease shall be presumed to have been incurred
in service, even though there is no evidence of such disease
during the period of service. This presumption is rebuttable
by affirmative evidence to the contrary. 38 U.S.C.A.
§§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309.
In this case, the veteran's service medical records reflect
that he had some pertinent complaints at entry and on a
medical history form at separation, he checked the block
indicating that he had or had had nervous trouble. However,
there are no clinical records of any complaints, symptoms or
diagnoses of any psychiatric disorder, and the psychiatric
evaluation conducted as part of separation medical
examination was normal.
The veteran did not refer to a psychiatric condition when he
submitted his initial claim for VA disability benefits in
October 1968 and when he was examined by the VA in October
1969 the psychiatric evaluation was normal. The veteran
initially claimed service connection for a psychiatric
condition in December 1974 which was several years following
his separation from military service and a psychiatric
condition, diagnosed as exogenous depressive reaction, was
diagnosed when he was hospitalized by the VA in late 1974 and
early 1975. The veteran was subsequently hospitalized at the
St. Elizabeth's Hospital for many years because of paranoid
schizophrenia.
The veteran has maintained that he began experiencing
auditory hallucinations during military service, while
serving in Vietnam and his recent attending physician at
St. Elizabeth's Hospital, Dr. Kaufman, has expressed the
opinion that the veteran's mental disorder began during his
military service or was aggravated during service. However,
this opinion was based on medical history provided by the
veteran. Opinions by psychologists in December 1994 and
January 1995 to the effect that the veteran's mental
condition had developed during his military service and the
September 1997 opinion by Dr. Kelley to the effect that the
veteran's schizophrenia became clinically significant prior
to his military discharge are also based on medical history
provided by the veteran. The veteran was afforded VA
psychiatric examinations in January 1995, February 1997 and
May 1999 and the examiners indicated that the time of onset
of the veteran's schizophrenia could not be determined from
the record On the May 1999 examination the examiner
commented that there was no way to confirm whether or not the
veteran's psychiatric condition began during his military
service.
Several private physicians and psychologists have expressed
an opinion that the veteran's schizophrenia began during his
active military service based on medical history provided by
the veteran. The Board is not required to accept medical
opinions that are based on the veteran's recitation of
medical history. Godfrey v. Brown, 8 Vet. App. 113 (1995).
The diagnoses can be no better than the facts alleged by the
appellant. Swann v. Brown, 5 Vet. App. 229 (1993).
Accordingly, since the opinions were based on medical history
provided by the veteran, the Board does not attach
significant evidentiary weight to those opinions; especially
since they were rendered without access to the claims file.
Furthermore, the test for the establishment of service
connection is that the illness or injury which led to the
current disability was incurred or aggravated during service.
As examiners have noted, delusions and hallucinations can be
related to drug use/abuse as well as schizophrenia. The
veteran has a long and extensive history of such use/abuse.
Even if his recollections are correct, the cause is not
uniquely and exclusively due to a psychosis.
In the Board's judgment, the evidence of record does not
establish that the veteran's schizophrenia became manifest
either during his active military service or within the one
year presumptive period following his separation from
service; nor is it at least as likely as not that such was
the case. The Board has carefully reviewed the entire record
in this case, including the testimony presented by the
veteran at the Board hearing conducted in December 1996;
however, the Board does not find the evidence to be so evenly
balanced that there is doubt as to any material issue.
38 U.S.C.A. § 5107. Accordingly, it follows that service
connection for schizophrenia is not in order. 38 U.S.C.A.
§§ 1101, 1110, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309.
ORDER
Entitlement to service connection for paranoid schizophrenia
is not established. The appeal is denied.
ROBERT D. PHILIPP
Member, Board of Veterans' Appeals